DURABLE POWER OF ATTORNEY COVERING HEALTH CARE STATE OF TENNESSEE COUNTY OF SHELBY KNOW ALL MEN BY THESE PRESENTS that I, _________________________________________, the undersigned, of _________________________________________, do hereby make, constitute, and appoint _________________________________________ my true and lawful Attorney in Fact for me and in my name, place, and stead, on my behalf, and for my use and benefit in accordance with the provisions set forth hereinbelow. If the Attorney in Fact named is unable or unwilling to serve, said Attorney in Fact shall be succeeded by _________________________________________. If more than one Attorney in Fact is designated, any one Attorney in Fact may exercise any and all of the powers granted herein without the approval or joinder of the other Attorney(s) in Fact. No third party dealing with any one Attorney in Fact shall be required to seek or secure the signature or approval of the other Attorney(s) in Fact. 1. Durable Power. This Power of Attorney is specifically given pursuant to the provisions of the Durable Power of Attorney for Health Care Act (Tenn. Code Ann. Section 34-6-201 et seq.). Accordingly, all Acts done by the Attorney in Fact pursuant to this Power of Attorney shall have the same effect and inure for my benefit and bind me and my successors in interest as if I personally performed said act. In addition, all acts done by my Attorney in Fact pursuant to this Durable Power of Attorney, during any period of disability or incapacity, shall have the same effect and inure to my benefit and bind me and my successors in interest as if I were competent and not disabled. 2. Revocation of Prior Documents. This Power of Attorney revokes all Powers of Attorney for health care previously executed. 3. Powers Granted. This Power of Attorney is intended to be a Durable Power of Attorney for Health Care. My attorney in fact is fully authorized to contract for my entry into, maintenance at, or release from any hospital, convalescent center, nursing home or other health care institution, health care provider, or health care facility, including the authority to approve or disapprove any proposed medical care, treatment, service or procedure to maintain, diagnose, or treat any physical or mental condition, any surgery, or any other medical care as the term is defined by Tennessee Code Annotated Section 32-11-103(5). The authority granted herein shall include the right to provide consent, to refuse to consent, or to withdraw consent for any such treatment. It is the intention under this paragraph to grant unto the Attorney in Fact all powers and authority which may be granted unto an Attorney in Fact pursuant to the Tennessee Durable Power of Attorney for Health Care Act (Tenn. Code Ann. Section 34-6-201 et. seq.). In this regard, the Power of Attorney shall not terminate at my death as same relates to any authority granted pursuant to said statute. 4. Special Provisions. The powers granted herein shall include but shall not be limited to the situation wherein I am suffering from an illness or condition from which my attending physician has determined that there can be no recovery and that death is imminent and that the application of life-prolonging procedures would serve only to artificially prolong the dying process. In this regard, this decision to withhold or withdraw such procedures may be made by the Attorney in Fact thereby permitting me to die naturally with only the administration of medicines or the performance of any medical procedure deemed necessary to provide me with comfortable care or to alleviate pain. 5. HIPAA Authority. I intend by this Power of Attorney to designate the individual or individuals who shall have authority to act on my behalf in making decisions related to my health care. In exercising such authority, my agent shall constitute my “personal representative” (as defined in 45 CFR §164.502(g)(1) and be treated as I would for all purposes of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 USC §1320d and 45 CFR §§160 and 164, and as such shall (1) have access to all my “individually identifiable health information,” including any “protected health information” (as those terms are defined in the regulations under HIPAA at 45 CFR §160.103), verbal or written; (2) possess, without limitation, my right of access to inspect and obtain a copy of protected health information about me as required by HIPAA at 45 CFR §164.524; and (3) possess, without limitation, my right to an accounting of disclosures of protected health information as required by HIPAA at 45 CFR §164.528. My agent’s exercise of the powers under this Paragraph shall not be deemed events: (1) in which treating my agent as personal representative could endanger me for purposes of 45 CFR §164.502(g)(5)(i)(B) or (2) in which it is not in my best interest for my agent to be treated as my personal representative for purposes of 45 CFR §164.502(g)(5)(ii). This authority applies to any information governed by HIPAA and may not be revoked except by revocation of this document as provided herein, which revocation may not be made by an extrinsic document unless such document specifically refers to this Power of Attorney. 6. Photocopies. My Attorney in Fact is authorized to make photocopies of this instrument as frequently and in such quantity as my Attorney in Fact shall deem appropriate. Each photocopy shall have the same force and effect as any original. WITNESS my hand, this _______ day of ___________________, _______. _________________________________ _________________________________________ STATE OF TENNESSEE COUNTY OF SHELBY On this _______ day of __________________, _______, before me, a Notary Public, personally appeared _________________________________________, known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that ______________________________ executed it. I declare under penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud or undue influence. _________________________________ NOTARY PUBLIC My commission expires: ___________________ WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal document. Before executing this document you should know these important facts. This document gives the person you designate as your agent (the attorney in fact) the power to make health care decisions for you. Your agent must act consistently with your desires as stated in this document. Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive. Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be stopped or withheld if you object at the time. This document gives your agent authority to consent, to refuse to consent or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose or treat a physical or mental condition. This power is subject to any limitations that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court can take away the power of your agent to make health care decisions for you if your agent: (1) authorizes anything that is illegal; or (2) acts contrary to your desires as stated in this document. You have the right to revoke the authority of your agent by notifying your agent or your treating physician, hospital or other health care provider orally or in writing of the revocation. Your agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document. Unless you otherwise specify in this document, this document gives your agent the power after you die to: (1) authorize an autopsy; (2) donate your body or parts thereof for transplant or therapeutic or educational or scientific purposes; and (3) direct the disposition of your remains. If there is anything in this document that you do not understand, you should ask an attorney to explain it to you.